The localisation of precisely where pain is coming from in the pelvis and abdomen is equally as difficult for the patient as it is for the doctor to ascertain. Therefore, there are several multidisciplinary conditions that can cause chronic pelvic pain and cause overlapping similar symptoms. Urological causes include renal stones or interstitial cystitis. Gastroenterological causes include functional bowel disorders like IBS, or inflammatory bowel disease. Cyclical pain tends to suggest a gynaecological cause and a possible endometriosis diagnosis. All of these pains tend to be pains of a visceral type that cause fatigue, heaviness, dragging and aching and even nausea & vomiting. The other type of pain is somatic pain and this tends to be neurological in origin and be stabbing, erratic, electrical sensations with numbness, pins and needles sensations and sometimes altered bowel, urinary or sexual function. These need specialised diagnosis and management. Muscle spasm related pain may cause deep or superficial vaginal pain and may benefit from specialised pelvic floor manipulation offered by a variety of subspecialties. Central sensitisation pain syndromes may benefit from psychological input and counselling.
Because of this potential variation in diagnoses a full assessment is crucial to guide the endometriosis specialist towards the most likely causes of pain in each particular woman's case. This sometimes requires the input of other experts in their fields. At The Endometriosis Clinic we have gathered a range of such experts to refer onto for second opinions and assistance in care.
This is perhaps the most crucial part of the assessment and is as important in what it excludes as what it finds. With a detailed expert scan prior to consultation we can proceed to a meaningful discussion immediately about treatment. This requires an expert level of scanning, and for this reason we do not do our own scans and instead send women to the Gynaecology Ultrasound Centre (http://www.ultragyn.co.uk) in Harley Street for scanning by Mr Davor Jurkovic or one of his team of experts in gynaecological and endometriosis scanning. This is one of the world's leading centres. With the information from these scans we can reliably decide upon whether simple or complex surgery is an option, drug therapy or whether you may need a referral to another specialist.
Women who are suspected of having somatic neurological pain need expert assessment by a specialist in neurological pelvic pain. These specialists are rare to find as most pain clinics are quite generic and formulaic in their approach and generally involves trial of neuromodulation drugs like Gabapentin and Duloxetine without deeper investigation into the exact underlying cause. We may refer to Dr Andrew Baranowski who practises at The National Hospital for Neurology and Neurosurgery at Queens Square, and has a private practice close to our clinic (http://www.apbuk.net). Detailed assessments may include high resolution MR Neurography, electrical conduction studies, nerve blocks and neuromodulation, referral on for physiotherapy and psychological intervention, and sometimes referral back to us for consideration of specialist neurosurgical intervention either in UK or by referral onto an expert in Switzerland.
We see a number of European women with recurrent miscarriage problems who have been recommended to have surgery by Dr Jeffrey Braverman (sadly deceased), who was the founder and director of Braverman IVF & Reproductive Immunology in New York City, USA (http://www.preventmiscarriage.com/about-us.html), and we also may refer women to this clinic for complex fertility issues.
Women who wish to remain more local, or who have less complex issues, we tend to refer to The Lister Fertility Clinic in London (https://ivf.org.uk).
Some women may wish to consider egg or embryo freezing prior to any endometriosis surgery so they have a back up plan as there is a small risk of significant ovarian damage in the presence of endometriomas and poor ovarian reserve results.
We often do not need to perform MRI scans as we have access to excellent ultrasound services. However sometimes we need to review MRI scans that women have had done in other centres and there may be a charge for this. If we do need to perform an MRI then we use Dr Priya Narayanan, an expert radiologist in nerve and endometriosis MRI (.https://www.hcahealthcare.co.uk/consultants/d/dr-priya-narayanan).
Also, we sometimes have women with coexisting or separate uterine fibroid problems (uterine myomas). These need MRI assessment on occasions, especially if the patient is considering uterine artery embolisation as a treatment option (UAE) as well as possible surgical removal of fibroids. For such cases, we refer to Dr Woodruff Walker, one of the world’s leading exponents of uterine artery embolisation, and an expert in MRI for deep infiltrating endometriosis (http://fibroids.co.uk).
Colorectal and Gastroenterology
With severe cases of deep infiltrating endometriosis the rectum and/or sigmoid colon are often also involved in the pelvis. Most cases we can manage by shaving endometriosis from the bowel surface without the need for opening the bowel. Occasionally we require the assistance of a colorectal surgeon during complex operations and expert cover is provided for us by Mr Edward Westcott (http://www.londonbridgehospital.com/LBH/consultant-det/mr-edward-d-a-westcott/). Also, if we predict that the chances of needing a bowel procedure are higher than normal then we will arrange for you to meet Mr Westcott before surgery to discuss this.
In the same way that endometriosis causes bladder issues, it frequently causes functional bowel problems also. These can include constipation, diarrhoea, emptying difficulty and strictures amongst others. Therefore we also have direct referral pathways to specialists in gastroenterology and functional pelvic floor issues that we use to optimise pre, peri and post operative function where appropriate.
Sometimes we require urological support in complex operations to insert stents into the ureters to protect them against leaks, or to re-implant ureters into the bladder if it is not possible to save them. We are fortunate to work in conjunction with international ureter expert Mr Daron Smith, consultant urologist at University College Hospital (https://www.kingedwardvii.co.uk/consultants/mr-daron-smith) are referred to him for pre-operative assessment where we believe this to be necessary.
Most endometriosis patients have significant bladder symptoms that are caused by irritation of the pelvic autonomic nerves by inflammation caused by adjacent endometriosis. These often improve with treatment. However occasionally we suspect bladder pain syndromes, like interstitial cystitis, that are difficult to diagnose and manage and so they need an expert with a true interest in this area. We refer our patients requiring a fuller bladder assessment on to Mr Rizwan Hamid at London Urology Associates, who also practises at The Princess Grace Hospital (http://www.lua.co.uk/the-urology-team/members/rizwan-hamid/)
The most common sites where endometriosis is found outside of the pelvis are 1. the caecum and appendix meaning appendicectomy or right hemicolectomy are sometimes required and 2. the diaphragm muscle that separates the chest and abdominal cavities from each other. This can cause a multitude of cyclical or constant chest symptoms including: shoulder pain (more common on the right), chest pain, rib pain, shortness of breath, upper back pain or scapula pain amongst others. Previously thought to be rare, we are now seeing many more women that suffer from this as we specifically ask questions in our assessments that would suggest this problem.
Very few endometriosis centres have much experience of endometriosis presenting in this way. For the past few years we have been building our experience in this area and now offer a very comprehensive service with a specialist multidisciplinary team to manage this challenging variation. To manage this effectively we need access to both sides of the diaphragm from the chest and from the abdomen and to be able to mobilise the liver out of the way to comprehensively assess the lower surface. Robotic surgery has been revolutionary in improving the feasibility and quality of this technique. We usually perform several surgeries a month for this and believe we are now one of the most experienced centres in Europe.
The team brings together three robotic surgery experts in their own areas and comprises of Peter Barton-Smith, Long Jaio, Professor of hepatobiliary surgery at Imperial College, London (https://www.imperial.ac.uk/people/l.jiao), and Mr Tom Routledge, Consultant Thoracic Surgeon at Guy's Hospital, London (https://www.guysandstthomas.nhs.uk/our-services/consultant-profiles/thoracic-surgery/tom-routledge.aspx).